In 2003, then-President George
W. Bush signed into law a new
measure to combat the global
AIDS crisis. The President’s
Emergency Plan for AIDS Relief, or PEPFAR,
was one of the most widely recognized accomplishments
of his administration. At the
dedication of his presidential library this past
April, Presidents Carter, Clinton, and Obama
all heaped praise on Bush for saving millions
of lives in Africa.

Yet from the start, PEPFAR was saddled
with funding restrictions that undermined
efforts to slow the spread of HIV. Among
those provisions were rules that rigidly tied
funding to support for premarital sexual
abstinence. For all of the good that PEPFAR
has done, such restrictions have compromised
the health and human rights of the
law’s intended beneficiaries—women and
girls, in particular.

At the Center for Health and Gender
Equity (CHANGE), we spent nearly a decade
working to change federal law and to revise
administrative policy on HIV prevention.
We partnered with a broad coalition of advocacy
groups—organizations that focus
on AIDS research and prevention, women’s
health, and human rights—to push for policy
changes in the face of fierce opposition. As a
result of our joint advocacy, the US Congress
in 2008 passed legislation that eliminated an
earmark for abstinence-only programs, and
in 2011 the Obama administration replaced
the Bush-era abstinence policy with policy
guidance that supports a wide range of measures
to counter the AIDS epidemic. Today,
thanks to these legislative and administrative
achievements, PEPFAR funding supports
prevention programs and interventions that
are based on proven best practices, a commitment
to human rights, and a respect for
scientific research.

Reaching that point was an extraordinary
challenge. It required patience, persistence,
and years of grindingly slow trench
work. Change doesn’t happen overnight.
Flaws in PEPFAR policy that might seem
self-evident on the ground in Botswana
and Zambia are all too easily ignored in the
power corridors of Washington, DC, where
ideology often takes precedence over science
and human rights. Again and again,
we watched in frustration as members of
Congress and other policymakers rejected
science-based arguments in favor of policies
that reflect narrow views of morality—views
that do not accord with social reality. The
struggle against such attitudes made the
already Herculean effort to save lives even
more difficult. Ultimately, however, we were
able to marshal evidence-based research to
improve US global HIV/AIDS policy.

Good Program, Flawed Policy

By 2003, the AIDS crisis had reached a sobering
level of intensity. That year, according
to the United Nations’ annual AIDS report,
4.3 million people became newly infected
with HIV. During that period, moreover,
the patterns of infection were shifting in
significant ways. In sub-Saharan Africa,
AIDS was on its way to becoming a women’s
disease. Today, about 60 percent of people
in the region infected with HIV are women.
In many countries, the highest rates of new
infections are among young married women
and sexually active adolescent girls. Worldwide,
unprotected sex accounts for 80 percent
of new HIV infections.

Despite evidence of those realities, PEPFAR
in its original form contained several elements
that hampered prevention efforts. Most
distressingly, the law included an “abstinence
earmark”—a requirement that one-third of
all funds allotted to preventing the sexual
transmission of HIV be spent on providers
that promote an abstinence-until-marriage
policy. This policy became known as the ABC
approach: Abstain until marriage. Be faithful in
marriage. And if those steps
fail, use Condoms.

In effect, US law promoted
the erroneous assumption
that sex within
marriage is always safe. In
fact, women from Botswana,
Nigeria, Uganda, and Zambia—4 of the 15 nations designated
as target countries under
the PEPFAR law—have
told us that they contracted
HIV from their husbands.
Hard evidence supports this
anecdotal information: Studies
show that most HIV infections
acquired during heterosexual
sex occur within
couples who are married or
living together.

The ABC policy stigmatized the use of
condoms, treating them as a last-resort option
that was relevant only to those who are
sexually immoral. Under the ABC model, a
woman could hardly ask her husband to use
a condom; doing so would be tantamount to
accusing him of infidelity, or to admitting
her own infidelity.

The law also included a provision that
became known as “the anti-prostitution loyalty
oath.” It required any organization that
receives PEPFAR funds to make an explicit
pledge in opposition to prostitution and
sex trafficking. As a result, sex workers—a
population that is at very high risk of HIV
infection—often became ineligible for treatment
and prevention programs.

Our best opportunity to change these
policies came in 2008, when Congress was
due to reauthorize the law. US Representative
Tom Lantos, then chairman of the
House Foreign Relations Committee, had
drafted a bill that not only removed the abstinence
earmark and the anti-prostitution
pledge, but also added a new provision that
sought to integrate family planning into
HIV-prevention programs. Family planning
should be an element of PEPFAR, we
believe, because women who are at risk of
unintended pregnancy also tend to be at
risk of HIV infection. Research, moreover,
shows that linking family planning to HIV
interventions increases both awareness and
use of HIV-prevention services.

As final debate on this bill began in early
2008, Lantos died of cancer. His death created
a void that we could only partially fill. Opponents
came out swinging. They accused us of
“hijacking” PEPFAR to turn it into an “abortion
bill.” They suggested that providing treatment
for sex workers amounted to “pimping.”
Our allies in Congress became skittish, and
our coalition frayed. As a result, our push to
include a family planning provision in the bill
fell short. We also failed to make headway
against the anti-prostitution rule. Still, the reauthorization
bill that passed in 2008 brought
a significant change to how the US government
funds global HIV-prevention programs.
With that law, which remains in effect today,
Congress jettisoned the abstinence-funding
requirement. (PEPFAR administrators, however,
must notify Congress if less than half of
the money spent on HIV prevention goes to
abstinence-based programs.)

The legislative struggle in 2008 set the
stage for landmark policy changes under
the Obama administration. In 2011, for example,
the administration replaced the ABC
policy with comprehensive prevention guidance.
And although PEPFAR legislation remains
silent on family planning, it no longer
prohibits use of that policy option: US
officials now have the flexibility to develop
and implement PEPFAR-funded programs
that combine HIV prevention with family
planning measures.

Science-Based Strategy

Achieving these policy changes required us to
mount an advocacy campaign that unfolded
on multiple fronts. We used old methods (a
postcard campaign, a call-in day) and new
ones. Our online operation made information
easily accessible to activists, policymakers,
and members of the public. We recruited
grassroots activists in key states, and we
took our campaign to political “outsiders,”
encouraging them to apply pressure on lawmakers
in their home districts. We built a
strong coalition that encompassed groups
as disparate as Planned Parenthood and the
United Methodist Church. To publicize our
cause, we partnered with a celebrity group
that included Ed Harris, Bonnie Raitt, and
Alfre Woodard.

Our most persuasive messengers were
African women on whom PEPFAR had a
direct impact. These women spoke at public
forums and met with lawmakers in venues
where they could share their personal stories.
On one occasion, for example, I took an
HIV-positive women’s-health advocate from
Botswana to meet with high-ranking members
of the Senate Foreign Relations Committee.
No one could have explained more
passionately than she did the critical need
for a comprehensive prevention program.

But the real game changer came in the
form of science-based research. We pressed
lawmakers to authorize studies that would
examine the effectiveness of PEPFAR. Members
of Congress might reject our facts and
figures, but it would be much harder for them
to dismiss the findings of congressionally
mandated reports. In one such report, the
Government Accountability Office (GAO)
concluded in 2006 that the abstinence-based
funding requirement “presented challenges”
for 17 of the 20 PEPFAR country teams that
the GAO studied. A report by the Institute
of Medicine (IOM), an arm of the National
Academy of Sciences, went a step further.
The authors of that report, which came out
in 2007, recommended eliminating the abstinence-
until-marriage funding restriction.

Subsequent research has not only supported
our advocacy project, but also vindicated
it. A far-reaching evaluation of PEPFAR
that IOM published this past February found
that recent revisions to the law had improved
the effectiveness of HIV-prevention programs
for people who live daily at elevated
risk of the disease. The report, requested
by Congress, confirmed that policy changes
in Washington had substantially improved
in-country programs by including more comprehensive
approaches.

The elimination of the abstinence-only
policy remains tenuous. That’s why the latest
IOM report is so crucial. We now have
clear evidence that removal of the abstinence
earmark and implementation of
the 2011 policy guidance have given people
greater access to HIV-prevention programs
that meet their needs. Thanks to a
rare confluence of factors, we are thus able
to demonstrate the real impact of our ongoing
advocacy project.

We will continue to press for changes that
will make more people (including sex workers)
eligible for PEPFAR programs. We will
also continue to push for increased awareness
of the role that family planning can play in the
prevention and treatment of HIV. Meanwhile,
as PEPFAR celebrates its first decade of existence,
it is better equipped to stem the AIDS
epidemic. The key to that outcome, we believe,
has been the marriage of science-based
research and rights-based health policy.

Serra Sippel is president of the Center for Health and
Gender Equity, an advocacy organization that promotes
the health and human rights of women and girls by seeking
to improve US policy. She writes extensively on US foreign
policy and global women’s rights.